Postpartum Hemorrhage

Definition

ACOG defines postpartum hemorrhage as cumulative blood loss of greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process. 2 However, the WHO defines this as >500 ml blood loss. 4

Treatment

In order of preference once postpartum hemorrhage is identified. 

  1. Fluids – Balanced solution bolus (NS, LR) 
  2. Medical Therapy – see table below
  3. Blood products – In escalating order
    • 2 units PRBCs
    • 2 units FFP
    • Massive transfusion protocol (pRBCs, FFP, Platelets 1:1:1)
  4. Interventions
    • Bakri Balloon – insert under ultrasound, inflate with 300-500 ml sterile water or saline, secure to leg for traction.
    • Compression / B-lynch suture
    • Uterine artery ligation
    • Hysterectomy

Medication

Dosage

Considerations

First Line Agent

Oxytocin

• 10-40 units diluted in 500 1000 mL NS IV at 500 mL/hr (10-40 units/hr)

OR

• 10 units IM

•Contraindications are few

•Adverse effects may include

nausea or vomiting

•Hyponatremia can occur with prolonged dosing

•IV push may cause hypotension

Second Line Agent

Methylergonovine

• 0.2 mg IM q2-4h as needed

•Avoid in patients with hypertension, pre-eclampsia, cardiovascular disease, or hypersensitivity to this medication

•Avoid IV administration, which may cause severe hypertension

•Adverse effects may include nausea or vomiting

Carboprost (Hemabate®)

• 250 mcg IM
• May repeat q15min up to 8 doses

•Contraindicated in patients with asthma

•Use with caution in patients with hypertension or with active cardiac, pulmonary, or hepatic disease

•Adverse effects may include nausea, vomiting, headache, fever, chills, bronchospasm, or hypertension

Misoprostol (Cytotec®)

• 800-1000 mcg PR

OR

• 600 mcg PO

OR

• 800 mcg SL

•Avoid use in patients with

hypersensitivity to prostaglandins
•Adverse effects may include

nausea, vomiting, diarrhea, headache, or fever

Tranexamic acid

• 1 g in 100 mL NS IV administered over 10 min

• May repeat once after 30 min

•Maximum benefit if administered within 3 hours of delivery
•Contraindicated in patients with active intravascular clotting

Abbreviations: IM, intramuscular; IV, intravenous; NS, normal saline; q, every; PO, by mouth; PR, rectally; SL, sublingually.

Etiology

  • Tone – Atony is the most common cause. Treat with bimanual massage immediately.
  • Tissue – Consider retained products. 
  • Trauma – Laceration
  • Thrombin – Coagulopathy (DIC) – transfusion

Epidemiology

Pregnancy related mortality in the US is increasing. Maternal hemorrhage remains the leading cause of maternal mortality worldwide. 3,4

Source: CDC Pregnancy Mortality Surveillance System

Hemorrhage is the 4th leading cause of pregnancy related death. 

Source: CDC Pregnancy Mortality Surveillance System

Considerable racial/ethnic disparities exist in this population. 

Source: CDC Pregnancy Mortality Surveillance System

Further Reading

Maternal Hemorrhage and Severe Hypertension/Pre-eclampsia: Identification and Management in the Emergency Department Date Release: Sep 2021 This course reviews evidence-based recommendations to improve care and outcomes for pregnant and postpartum patients with hemorrhage or severe hypertension. Emergency Medicine Practice and Pediatric Emergency Medicine Practice subscribers receive this content & CME Credit absolutely free!

References

  1. Ashoo S. Maternal hemorrhage and severe hypertension/pre-eclampsia: identification and management in the emergency department. Emerg Med Pract. 2021 Sep 15;23(Suppl 9):1-19. PubMed
  2. Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-e186. doi: 10.1097/AOG.0000000000002351. PubMed, PDF
  3. Pregnancy Mortality Surveillance System, CDC
  4. WHO recommendations for the prevention and treatment of postpartum haemorrhage, WHO
  5. Tranexamic Acid – Drug Summary. Prescribers’ Digital Reference. Accessed September 1, 2021.

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